supalak khemthong, tisha saravitaya

J Nurs Sci Vol.28 No.3 Jul - Sep 2010

Journal of Nursing Science8

Knowledge Translation of Self-management Concepts for Thais

Corresponding author: S. KhemthongE-mail: [email protected]

Supalak Khemthong PhDChair for Occupational TherapyDivision, Faculty of Physical Therapy,Mahidol University, Nakhon Pathom,Thailand.

Tisha Saravitaya MSOTFreelance Occupational Therapist,American Board for Certification inOccupational Therapy, New Jersey, USA.

J Nurs Sci 2010;28(3): 8 - 12

Abstract:Increased prevalence of chronic illness is associated with the aging of the world population and its impact on behavioural changes of the individual, family, community, and health care providers. Self-management concepts demonstrate the best evidence of health outcomes. Current health care systems are not sustainable, but many forms of self-management concepts are widely developing as a part of the solution based on a client-centered intervention and support of health care providers in Thailand.

Keywords: self-management, knowledge translation, chronic illness

Supalak Khemthong, Tisha Saravitaya

Self-management concepts Self-management concepts are strategies to minimize the burdens of chronic illness which are increasingly becoming the focus of health care service integrated with policy and research. Several definitions of self-management concepts have been written using qualitative research. This paper uses a definition of self-management concept, written by Curtin University Self-management Team, defined as an individuals’ ability to manage living activities in relation with treatment of chronic illness, leading to active participation in his or her chosen way of life.1 Health care providers should educate individuals to recognize how they are managing chronic illness into three dimensions: the symptomatic process of chronic illness, the emotional consequences of living with chronic illness, and the behavioral changes of life role activities. The experiences of people living with chronic illness were studied in early 1988.2 This study showed that initially individuals managed symptoms by taking medication and receiving therapeutic activities. Second, they managed the emotions by coping with depression, and finally they managed their role behaviors that included performing new life activities.

Clinical research on self-management Self-management concepts have been shown to be effective in recent clinical research. For example, 169 people with multiple sclerosis were randomly assigned to a six-week energy conservation course (N = 78) or a delayed control group (N = 91).3 Mixed effects analysis of variance models showed positive effects of the program on fatigue, self-efficacy, and quality of life (QoL). The effectiveness of Self-Management Arthritis Relief Therapy (SMART) was determined in two studies: 1) participants randomized to SMART (N = 468) or usual care (N = 413), and 2) participants randomized to SMART (N = 166) or Arthritis Self-Management Program (ASMP) (N = 142).4 Analyses of covariance (ANCOVA) showed that SMART at 1 year decreased disability, decreased pain, decreased depression, improved role function, and increased self-efficacy when compared with usual care or ASMP. All those variables were improved from baseline in both SMART and ASMP. The effectiveness of ASMP and Chronic Disease Self-Management Program (CDSMP) were also determined for 239 and 116 clients, respectively.5 The ASMP is a six-session program (two hours per week) of knowledge management about exercise, pain,


Journal of Nursing Science 9

nutrition, fatigue, joint protection, medications, stress and depression, healthcare team, treatment evaluations, and problem solving with arthritis. Where as the CDSMP is a six-session program (two and a half hours per week) of knowledge management about exercise; symptoms and cognitive techniques, nutrition, fatigue and sleep, community resources, medications, anger and depression, communication with health professionals, problem-solving, and decision-making. Both programs had positive effects on fatigue, self-efficacy, QoL, health behaviors (stress management and role activities). The CDSMP has improved those health outcomes and decreased health care utilization for people with heart disease, lung disease, stroke, or arthritis (N = 831).6 Thus, the self-management concepts have been developed into relevant programs contributing positive outcomes for people with both generic and specific conditions. To date, self-management concepts have emerged into the health service of disabilities such as multiple sclerosis, blindness and cerebral palsy.1 Five essential skills that health care providers work on with all clients who are participating in all self-management programs are: problem solving, decision making, resource utilization, clients/health care provider partnership, and taking action.2 Therefore, clients who have participated in and mastered the content in the self-management programs are more likely to use less health professional time, have lower health utilization overall, and a better quality of life.1 Importantly, the self-management programs should be created by evaluating the client’s needs and circumstances.1 Gaining acceptance and support from health care providers seems to be a successful key of the programs, but the self-management programs have been educated in different ways. For instance, clients are educated using self-management programs whereas health providers are educated in professional development and research evidence. Most clinical research has focused on effectiveness of self-management programs based on self-efficacy theory, however little research has focused on “why and how” it

works through teaching and learning components (e.g., peer interaction, empowerment, mastery competence, etc).1

Thai society and self-management A review of literature explored the implementation of self-management concepts for chronic conditions in Thailand and its effect on the quality of life on the individual and caregivers. Chronic conditions (i.e. cancer, diabetes type II, asthma, and schizophrenia) can cause a large burden of physical and psychological ill health, treatment costs, careful health management requirements, and lifestyle adaptations to prevent, maintain, and manage related health complications for Thais.7,8,9 The idea of self-management can facilitate better health outcomes of patients, caregivers, and stakeholders involved.7,8 Components of self-management involve the community and health care organizations creating and utilizing the resources to meet the needs of patients. Leadership training and promoting participation in the community were desired by Thai focus groups in order to empower and prepare patients to solve chronic disease complications and effectively manage and address health and health care.7,9 Focusing on the concepts of empowerment and problem solving for patients in order to adopt a more positive, proactive, and adaptive perception can facilitate improvements in the patient’s emotional well-being with chronic conditions.7 For example, practicing Buddhism (i.e., giving merit, praying, and meditation) for many Thai patients allowed them to take control and manage their complications and relieve related symptoms.8,10 Meditation was effectively used as an alternative mind-body healing and coping method to look deeply into oneself within the spirit of self-inquiry and self-understanding.10 When the patients used meditation and had belief in the Buddhist religion, they were able to realize that feelings of anxiety, depression, and fright/fear were the main causes of fatigue.8 Then, they focused on coping with the physical and psychological impacts of fatigue on the individual’s ability to function in their daily lives.8,18

Educating the health care professional can assure the delivery of effective, efficient clinical care and



self- management support by becoming aware of the impor-tance of a subjective patient view on his or her own health condition and its complications.8,11,12 In addition, applying the self-management concepts for relief of fatigue in Thai Bud-dhist cancer patients receiving radiation therapy (RT) can help health care professionals provide effective holistic inter-ventions by considering cultural and religious aspects.8 Broad-ening the awareness of healthcare professionals and acknowl-edging the importance of understanding how people with chronic conditions constitute their identity following their diagnosis offers insights into how they self-manage and adapt to living with chronic illness.6,10,11,12 Shifting from the psycho-educational concepts to the self-management concepts, participation in problem-solving groups were found to improve perceived QoL and decrease psycho-logical distress.7,13

Self-management concepts have been introduced in a variety of Thai community settings: parents and teachers looking after kids with autism and other special needs14 and case studies with fatigue secondary to chronic conditions or FSCC (i.e., low back pain, cancer, depression, stroke, arthritis).15,16 Using knowledge translation or KT 17,18 is a key factor associated with successful outcomes of those self-management concepts. KT has been defined as the creation of new knowledge and its implementation, including multidirectional communications, interactive and nonlinear process, multiple activities, relevant collaborations and use of research-generated knowledge.17 Informal meetings were started in order to reflect the gap between research evidence and clinical practice based on those self-management concepts. Program evaluations (i.e., needs assessment by focus group) were further conducted in order to develop practical models. These included The Occupational Therapy – Mahidol Clinic System or OT-MCS Model19 and the Life skills – Pyramid & Tree Models.20 The OT-MCS Model and its extended programs of leisure management was evaluated using randomized control trials21 and routine research, which is a scientific process of thinking and working with a productive outcome.16,18,22 These studies demonstrated the positive

outcomes of leisure management on QoL, self-efficacy, or reaction time in people living with stroke. Moreover, the Life skills – Pyramid & Tree Models were adopted by a private sector for community services and their implications as home and school programs (e.g., parenting programs for kids with sensory processing disorders or low vision) through mass communications.15

Consequently, those self-management programs have been generalized as health systematization of occupational therapy in Thai people with and without chronic illness. Such programs15 include self-management for students, leisure management for elderly, fatigue and leisure management, cognitive and psychosocial management, leisure management for COPD, and leisure management for mental health. However, specific research rationales for those programs would be conceptualized in combination with universal frameworks including the Curtin pARTicipation Model1, the Person-Environment-Occupation-Performance Model23, the International Classification of Functioning, Disability and Health24, the Recovery Model25 or the Ecology of Human Development Model.26 These frameworks provide clearer and wider knowledge translation of the self-management concepts into a common understanding for clients, families, communities, and health care professionals. In conclusion, self-management concepts have contributed health and societal benefit for Thais in some settings. Creative referral pathways, accessible supports, professional education, and effective programs should also be further developed in order to gain benefit for all stakeholders.1 I would finally acknowledge my supervisor, Prof. Tanya L. Packer who has recommended five strategies of health utilization based on the self-management concepts (4 years per strategy - action in parallel to all strategies) as follows: 1) provide resources and direction, 2) create referral pathways and ensure sustainable access, 3) select and develop successful programs, 4) build professional capacity into multidisciplinary teamwork, and 5) build research database and evaluation framework.


Journal of Nursing Science 11

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supalak khemthong, tisha saravitaya

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